Policy for Conditions for which over the counter items should not routinely be prescribed in primary care.

Transcription

1 Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group East Staffordshire Clinical Commissioning Group North Staffordshire Clinical Commissioning Group Stoke on Trent Clinical Commissioning Group Policy for Conditions for which over the counter items should not routinely be prescribed in primary care. Version: V1.0 Final Name & Title of Originator: Approved by the Joint Medicines Optimisation Group Ratified by The North Staffordshire and Stoke-on-Trent CCGs Planning and Commissioning Committee held in common Ratified in South Staffordshire by Dr Mani Hussain Associate Director Medicines Optimisation TBC 08/05/2018 Approved by South Staffordshire Area Prescribing Group on 15/06/2018 and ratified by individual CCG membership boards. Date Issued: 02/06/2018 Review Date: 02/06/2020 Target Audience: General Practice Community Pharmacies Clinicians at UHNM/ SSOPT/NSCH/SSSFT/BHFT Medicines Optimisation Team Contract Team Commissioning Team Finance

2 1.0 Background 1.1 As part of the Medicines Value Programme, NHS England in conjunction with NHS Clinical Commissioners has issued CCG guidance on conditions for which over the counter items should not be routinely be prescribed in primary care (March This CCG policy aims to incorporate the recommendations made in the NHS England NHS Clinical Commissioners guidance document as part of its on-going Medicine Optimisation QIPP Programme. 2.0 Conditions for which over the counter items should not be routinely prescribed in primary care 2.1 NHS England has identified over 569 million being spent on prescriptions for medicines, which could otherwise be purchased over the counter (OTC) from a pharmacy and other locations. 2.2 These prescriptions include items for a condition: That is considered to be self-limiting and so does not need treatment as it will heal or cure of its own accord; Which lends itself to self-care i.e. the person suffering does not normally need to seek medical advice and can manage the condition by purchasing OTC items directly. 2.3 These prescriptions also include other common items that can be purchased OTC, sometimes at a lower cost than that which would be incurred by the NHS; for which there is little clinical evidence. 2.4 For each condition (or item), the guidance states one of the following recommendations: That the item should not be routinely prescribed in primary care due to limited evidence of clinical effectiveness That a prescription for treatment of a condition should not primary care as the condition That a prescription for treatment of a condition should not primary care as the condition 2.5 The aim of the guidance is that by reducing spend on treating conditions that are self-limiting or which lend themselves to self-care, or on items for which there is little evidence of clinical effectiveness, these resources can be used for other priority areas that have greater impact for patients, support improvements in services and deliver long-term sustainability of the NHS. 2.6 Research shows that in many cases, people can take care of their minor conditions if they are provided with the right information, thereby releasing health professionals to focus on patients who have more complex or serious health issues. 2.7 As part of the implementation of this guidance, it is important that the CCGs need to supply patients with better information on signposting so that they are able to access the right service. This could be done through care navigation, 111 services, local promotion of self-care and pharmacy services. Page 2 of 11

3 2.8 It is important to note that this guidance is not intended to discourage patients from going to the GP when it is appropriate to do so. 3.0 Consultation 3.1 Following the launch of the NHSE OTC consultation guidance in Dec 2017 ( the CCGs have undertaken a local consultation regarding the implementation of the guidance. Prescribers and patients were all encouraged to review the recommendations and feedback to the CCGs as well as NHSE. 3.2 Having taken legal advice regarding the CCGs responsibility in engaging with the Public and service providers, the following was recommended: Taking all factors into account, whilst 12 week, full-blown consultation will not be required, clearly some level of engagement and involvement with professionals, patient groups and the wider public will need to precede formulation of local policy and implementation and the NHS England guidance implies this even if it does not explicitly say it. The CCG in parallel, to the national consultation has engaged with Practices, Patients and Patient groups. 3.3 The feedback from prescribers showed consensus agreement. Points were raised about giving prescribers some flexibility. 3.4 Feedback from patients included: People on low incomes may not self-treat adequately and therefore there is the risk that they will then present to emergency services with a condition that has deteriorated. Vulnerable patient groups e.g. frail elderly, patients with disabilities or mental health problems, care home patients etc. may struggle to access appropriate medication if not prescribed. There could be an adverse impact on children as they rely on adults to make purchasing decisions 3.5 The overall NHSE consultation findings can be accessed, which follow similar themes to local findings A discussion paper was also sent to LEAF in Jan The CCG will work with rural areas, with insufficient Pharmacy service provision to ensure that Patients are not disadvantaged. 4.0 Policy implementation and review 4.1 Under this policy, the CCGs advise that GPs and other prescribers follow the recommendations for each condition or item (Appendix 1) with due regard to general (Appendix 2). Page 3 of 11

4 4.2 General do not apply to vitamins, minerals, probiotics and those self-limiting conditions where there is limited evidence of clinical effectiveness for the treatments used (e.g. OTC items for cough, sore throat and infant colic). 4.3 There may be cases, where the clinician feels that the condition/item falls outside general or specific and they still wish to prescribe. 4.4 It should be noted that the CCG policy is guidance for primary care prescribers. The final decision to prescribe will remain with the prescriber. However, due regard needs to be given to professional guidance around resource management. Practices will be supplied with a letter that can be shared with Patients advising them that this is a CCG policy and support through the complaints procedures. 4.5 General Medical Council guidance requires doctors to take into account available resources and give due regard to agreed policy and guidance when making decisions to access to treatment. See General Medical Council guidance also states activities such as advising patients on the purchase of over the counter medicines and other remedies and providing written information to patients or advice given fall under the definition of prescribing. See /media/documents/prescribing_guidance.pdf_ pdf 4.7 The CCG Medicine Optimisation Team will conduct audits based on prescribing data to support the implementation of the policy and monitor ongoing compliance with the policy. Regular audit reports will be presented at the CCG Medicine Optimisation Group/Area Prescribing Committee. 4.8 The schedule of medicines listed in Appendix 1 will be reviewed when further national/regional guidance is issued from NHSE/NHS Clinical Commissioners. There is national expectation that further conditions/items will be added to Appendix 1 with time. 4.9 The CCG policy will also be reviewed if: There is new relevant national guidance The APC issues new verdicts on any new medicines and items Any applications for change to the status of specific medicines and items in the schedule are made by local clinicians and approved by the APC Every two years (as per the review date on front sheet) 5.0 Equality and Quality Impact Assessment 5.1 CCG Equality and Quality Impact Assessments have been conducted in addition to NHS England which is available at Page 4 of 11

5 5.2 Appendix 1: Conditions and OTC items which prescribing should be restricted Please refer to the full guidance and FAQs: FAQs: *The products highlighted below are included for illustration purposes only. This policy focuses on prescribing restrictions for the conditions identified. Condition\Item Example products* Recommendation Exceptions Probiotics Probiotic sachets probiotics should not be routinely prescribed in primary care due to limited evidence of clinical effectiveness. Exceptions ACBS approved indication or as per local policy. ACBS approved indication or as per local policy. Vitamins and Minerals Vitamin B compound tablets, Vitamin C effervescent 1g tablets, Multivitamin preparations. vitamins and minerals should not be routinely prescribed in primary care due to limited evidence of clinical effectiveness Medically diagnosed deficiency, including for those patients who may have a lifelong or chronic condition or have undergone surgery that results in malabsorption. Continuing need should however be reviewed on a regular basis. NB maintenance or preventative treatment is not an exception. Calcium and vitamin D for osteoporosis. Malnutrition including alcoholism (see NICE guidance) Patients suitable to receive Healthy start vitamins for pregnancy or children between the ages 6 months to their fourth birthday. (NB this is not on prescription but commissioned separately) Acute Sore Throat Lozenges or throat sprays of acute sore throat should not Red Flag symptoms Page 5 of 11

6 Condition/Item Example products* Recommendation Exceptions Cold Sores Antiviral cold sore cream of cold sores should not Immunocompromised patients. Red flag symptoms Conjunctivitis Antimicrobial eye drops and eye ointment. of conjunctivitis should not Red Flag symptoms Coughs and Colds and Nasal Congestion Cough mixtures or linctus, Saline nose drops, Menthol vapour rubs, Cold and flu capsules or sachets. of coughs, colds and nasal congestion should not Red Flag symptoms Cradle Cap Emulsifying ointment, Shampoos of cradle cap should not If causing distress to the infant and not improving Haemorrhoids Haemorrhoid creams, ointments and suppositories. of haemorrhoids should not Red Flag symptoms Infant Colic Simethicone suspensions lactase drops of infant colic should not Red Flag symptoms Page 6 of 11

7 Condition/Item Example products* Recommendation Exceptions Mild Cystitis Contact Dermatitis Sodium bicarbonate or potassium citrate granules Emollients, Steroid creams. of mild cystitis should not of contact dermatitis should not Red Flag symptoms Dandruff Antidandruff shampoos Antifungal shampoos for dandruff should not See Appendix 2 for general Diarrhoea (Adults) Loperamide 2mg capsules Rehydration sachets, for acute diarrhoea will not Dry Eyes/Sore(tired) eyes Eye drops for sore tired eyes Hypromellose 0.3% eye drops of dry or sore eyes should not Earwax Drops containing sodium bicarbonate, hydrogen peroxide, olive oil or almond oil. A prescription for the removal of earwax should not Excessive sweating (mild moderate hyperhidrosis) Aluminium chloride sprays, roll-ons, solutions. A prescription for high strength antiperspirants for the treatment of mild to moderate hyperhidrosis should not routinely be offered in primary care as the See Appendix 2 for general. Head Lice Indigestion and Heartburn Creams or lotions for head lice Antacid tablets or liquids Ranitidine 150mg Tablets OTC proton pump inhibitors e.g. omeprazole 10mg capsules. Sodium alginate, calcium carbonate or sodium bicarbonate liquids. of head lice will not routinely be offered in primary care as the condition is appropriate for of Indigestion and heartburn will not routinely be offered in primary care as the. Page 7 of 11

8 Condition/Item Example products* Recommendation Exceptions Infrequent Constipation Bisacodyl tablets 5mg Ispaghula Husk granules Lactulose solution of simple constipation will not Infrequent Migraines Migraine tablets Painkillers Anti-sickness tablets A prescription for the treatment of mild migraine should not routinely be offered in primary care as the Insect bites and stings Steroid creams or creams for itching. for insect bites and stings will not See Appendix 2 for general Mild Acne Benzoyl peroxide products Salicylic acid products of mild acne will not routinely be offered in primary care as the condition is appropriate for Mild Dry Skin Emollient creams, ointments and lotions of dry skin should not Mild to Moderate Hay fever/seasonal Rhinitis Minor Burns and Scalds Antihistamine tablets or liquids. Steroid nasal sprays Sodium cromoglicate eye drops Antiseptic Burns Cream, Cooling burn gel. of mild to moderate hay fever will not routinely be offered in primary care as the A prescription for minor burns and scalds should not. However more serious burns always require professional medical attention. Burns requiring hospital A&E treatment include but are not limited to: all chemical and electrical burns; large or deep burns; burns that cause white or charred skin; burns on the face, hands, arms, feet, legs or genitals that cause blisters. Page 8 of 11

9 Condition/Item Example products* Recommendation Exceptions Minor conditions associated with pain, discomfort and/fever. (e.g. aches and sprains, headache, period pain, back pain) Paracetamol 500mg tablets, Ibuprofen 400mg tablets, NSAID topical creams or gels Paracetamol Suspension of conditions associated with pain, discomfort and mild fever will not routinely be offered in primary care as the. Mouth Ulcers Antimicrobial mouthwash of mouth ulcers will not Nappy Rash Nappy rash creams for nappy rash will not Oral Thrush Anti-fungal mouth gels for oral thrush should not Prevention of dental caries Fluoride toothpastes Mouthwashes for oral thrush will not.... Ringworm/Athletes foot Athlete's Foot Cream Antifungal creams or sprays of ringworm or athletes foot will not routinely be offered in primary care as the Lymphoedema or history of lower limb cellulitis.. Sunburn/Sun Protection After sun cream Sun creams A prescription for sun protection should not Teething/Mild Toothache Antiseptic pain relieving gel Clove Oil Painkillers A prescription for high fluoride OTC toothpaste should not routinely be offered in primary care as the. Threadworms Mebendazole 100mg tablets of threadworm should not is appropriate for self-care. Page 9 of 11

10 Condition/Item Example products* Recommendation Exceptions Travel Sickness Travel sickness tablets for motion sickness will not Warts and Verrucae Creams, gels, skin paints and medicated plasters containing salicylic acid dimethyl ether propane cold spray of warts and verrucae will not. Page 10 of 11

11 Appendix 2- General Exceptions to the Guidance There are certain scenarios where patients should continue to have their treatments prescribed and these are outlined below: Patients prescribed an OTC treatment for a long term condition (e.g. regular pain relief for chronic arthritis or treatments for inflammatory bowel disease). For the treatment of more complex forms of minor illnesses (e.g. severe migraines that are unresponsive to over the counter medicines). For those patients that have symptoms that suggest the condition is not minor (i.e. those with red flag symptoms for example indigestion with very bad pain.) Treatment for complex patients (e.g. immunosuppressed patients). Patients on prescription only treatments. Patients prescribed OTC products to treat an adverse effect or symptom of a more complex illness and/or prescription only medications should continue to have these products prescribed on the NHS. Circumstances where the product licence doesn t allow the product to be sold over the counter to certain groups of patients. This may vary by medicine, but could include babies, children and/or women who are pregnant or breast-feeding. Community Pharmacists will be aware of what these are and can advise accordingly. Patients with a minor condition suitable for self-care that has not responded sufficiently to treatment with an OTC product. Patients where the clinician considers that the presenting symptom is due to a condition that would not be considered a minor condition. Circumstances where the prescriber believes that in their clinical judgement, exceptional circumstances exist that warrant deviation from the recommendation to Individual patients where the clinician considers that their ability to self-manage is compromised as a consequence of medical, mental health or significant social vulnerability to the extent that their health and/or wellbeing could be adversely affected, if reliant on To note that being exempt from paying a prescription charge does not automatically warrant an exception to the guidance. Consideration should also be given to safeguarding issues. Page 11 of 11